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<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<link href="{$css_path}/modules/systemapi/templates/default/css/print.css" rel="stylesheet" type="text/css" />
</head>


<body style="background-color:#ffffff;">
<div id="wrap_3">
		<div class="title_content_detail">Pre-authorize Transection<br>
			<span style="font-size: 16px; font-family: sarabun;">{$data.today}</span>
		</div>
		<div class="line"></div>
		<div id="area_title_description">
			<div class="text_title_description">
				<span class="text_black_title">Pre-auth ID: </span><span class="text_red_title">{$preauthId}</span>	
			</div>
			<div class="text_title_images"><img src="{$img_path}/{$img}"></div>			
		</div>
			
		<div class="showdetail"><br>		
			<table width="700" align="center" border="0" cellpadding="0" cellspacing="0" style="font-size:16px; font-family: sarabun;" >
				<tr>
					<td class="UnderLine"  colspan="4" align="center"><span class="text_black_bold">ข้อมูลกรมธรรม์</span></td>
				</tr>
				<tr>
					<td width="130" align="right">ชื่อผู้เอาประกัน :</td>
					<td width="220">{$policyData.name}&nbsp;&nbsp;{$policyData.surname}</td>
					<td width="130" align="right">บัตรประชาชน : </td>
					<td width="220">{$policyData.natid}</td>
				</tr>
				<tr>
					<td align="right">เลขที่่กรมธรรม์ :</td>
					<td>{$policyData.policy_no}</td>
					<td align="right">เลขที่บัตรประกัน :</td>
					<td>{$policyData.cardno}</td>
				</tr>
				<tr>
					<td align="right">วันเริ่มคุ้มครอง :</td>
					<td>{$policyData.effective}</td>
					<td align="right">วันสิ้นสุดความคุ้มครอง :</td>
					<td>{$policyData.expiry}</td>
				</tr>
				<tr>
					<td align="right"><span style="font-size: 20px; color: #000000; font-weight: bold;">สถานะกรมธรรม์ :</span></td>
					<td><span style="font-size: 20px; color: {$data.polstatus_color}; font-weight: bold;">{$policyData.polstatus_desc}</span></td>
					<td align="right">แผนความคุ้มครอง :</td>
					<td>{$policyData.plan}</td>
					
				</tr>
				<tr>
					<td align="left" colspan="4">{$policyData.memc_cover}</td>
					<!--
						<td align="right">ME Cover :</td>
						<td>{$policyData.me_cover} บาท</td>
						<td align="right">&nbsp;</td>
						<td>&nbsp;</td>
					-->
				</tr>
				<!--<tr>
					<td>&nbsp;</td>
					<td>&nbsp;</td>
					<td align="right">MC Cover :</td>
					<td>{$policyData.mc_cover} บาท</td>
				</tr>-->
			</table>		
							
			<table width="700" align="center" border="1" cellpadding="0" cellspacing="0" style="font-size:16px; margin-top:15px;">
				<tr>
					<td width="700" height="130" align="center" valign="top">
						<table width="650" align="center" border="0" cellpadding="0" cellspacing="0" height="120" >
							<tr>
								<td colspan="3" class="UnderLine2" align="center"><span class="text_black_bold">เงื่อนไขกรมธรรม์</span></td>
							</tr>
							<tr>
								<td  colspan="3" align="center" valign="top">{$paInfo.policy_condition}</td>
							</tr>
						</table>
					</td>
				</tr>
			</table>
							
			<table width="700" align="center" border="0" cellpadding="0" cellspacing="0" style="font-size:16px; margin-top:5px;" >
				<tr>
					<td height="175" align="center" valign="top">
						<table width="700"  align="center" border="1" cellpadding="0" cellspacing="1" >
							<tr>
								<td colspan="3" class="UnderLine2" align="center"><span class="text_black_bold">ประวัติการรักษา</span></td>
							</tr>
							<tr>
								<td class="UnderLine3"  align="center" valign="bottom">วันเกิดอุบัติเหตุ</td>
								<td class="UnderLine3"  align="center" valign="bottom">ค่าใช้จ่าย</td>
								<td class="UnderLine3"  align="center" valign="bottom">ICD10</td>
							</tr>
							{foreach from=$paClaimData item=item}
							<tr>
								<td align="center">{$item.acc_date}</td>
								<td align="center">{$item.paid} บาท</td>
								<td align="center">{$item.diags}</td>
							</tr>
							{/foreach}
							</table>
					</td>
				</tr>
			</table>													
			<table width="700" align="center" border="0" cellpadding="3" cellspacing="0" style="font-size:16px; margin-top:15px;" >
				<tr>
					<td width="700" height="130" align="center" valign="top">
						<table width="650" align="center" border="0" cellpadding="3" cellspacing="0" height="90" >
							<tr>
								<td colspan="3" class="UnderLine2" align="center"><span class="text_black_bold">บันทึกเกี่ยวกับ ผอป.</span></td>
							</tr>
							<tr>
								<td  colspan="3" align="center" valign="bottom">{$paInfo.note2hosp}</td>
							</tr>
						</table>
					</td>
				</tr>
			</table>
			
	</div>
</body>
</html>	